The affected area is identified and ultrasound gel is applied. A shockwave device is placed against the skin and delivers a series of acoustic pulses. Focused ESWT: high-energy pulses precisely targeted to the pathology. Radial ESWT: lower-energy waves spread over a wider area. A typical session delivers 1,500–3,000 pulses over 10–15 minutes. Most protocols require three to five sessions at weekly intervals. No anaesthesia is needed — though the treatment is uncomfortable.
ESWT is considered for chronic tendinopathies that have not responded to three to six months of structured rehabilitation — plantar fasciitis, calcific shoulder tendinitis, lateral epicondylitis (tennis elbow), patellar tendinopathy, Achilles tendinopathy, and greater trochanteric pain syndrome. It is also used for fracture non-union and myositis ossificans.
Physiotherapy (the primary treatment for tendinopathy), eccentric and heavy slow resistance exercise programmes, corticosteroid injection, PRP injection, and activity modification.
Outpatient clinic procedure. No fasting. Stop anti-inflammatory medication for 48 hours before (NSAIDs may inhibit the healing response that ESWT stimulates).
Evidence is strongest for plantar fasciitis (Level 1) and calcific shoulder tendinitis (Level 1). Approximately 60–80% of patients report significant improvement. Benefits develop gradually over six to twelve weeks after the treatment course.
Pain during treatmentExpected
The pulses are uncomfortable, particularly at higher energy levels. Tolerable for most patients.
Temporary pain flareCommon
Increased pain for 24–48 hours after treatment. Normal and expected.
Redness and bruisingCommon
At the treatment site.
Tendon ruptureRare
Theoretical risk of weakening a severely degenerate tendon. Very rare.
Skin breakdownRare
With very high energy. Rare with proper technique.
Nerve irritationRare
Temporary numbness in the treated area.
No anaesthesia. The treatment is tolerable — intensity is adjusted to the patient's comfort level.
Normal activities immediately. Avoid high-impact loading of the treated area for 48 hours. Continue (or begin) the structured rehabilitation programme — ESWT works best when combined with exercise. Benefits develop over six to twelve weeks.
Sessions at weekly intervals for three to five weeks. Assess response at six to twelve weeks after completing the course.
Does it work?
The best evidence supports ESWT for plantar fasciitis and calcific shoulder tendinitis. For other tendinopathies, evidence is moderate but growing. It is most effective when combined with a structured exercise programme, not as a standalone treatment.
Why can't I take anti-inflammatories?
ESWT works by stimulating an inflammatory healing response. Anti-inflammatory drugs may inhibit this response and reduce the effectiveness of the treatment.
Is it available on the NHS?
NICE has conditionally approved ESWT for calcific shoulder tendinitis and plantar fasciitis. Availability varies by region. It is widely available privately.